Discussion
Hiatal hernia may be transient or permanent and cause the stomach to
pass through the diaphragm and enter the chest. Surgical intervention,
including hernia reduction, closure of the esophageal hiatus, and
anti-reflux procedure, may be necessary for types II, III, and IV
hernias with severe esophagitis. It may also involve other abdominal
organs, as observed in the present case. The most common organs
associated with the stomach are the colon, small intestine and omentum.
A giant hiatal hernia has been reported frequently; however, cases of
giant hernia with pancreatic prolapse is extremely rare [4].
Stretching of the transverse mesocolon has been reported to increase the
mobility of the pancreas owing to greater relaxation of the posterior
adherent fascia. A recent study of a human cadaver reported a posterior
pancreatic fascia covering the posterior surface of the main body of
pancreas but was unable to locate the anterior renal fascia, possibly
because of age-related degeneration of the adrenal glands [5]. In
the elderly, the pancreas may be more mobile owing to connective tissue
degeneration, making it more likely to migrate from a hiatal hernia.
Pancreatic hernias are asymptomatic [6] [7], and most cases are
discovered incidentally during CT scans performed to evaluate features
characteristic of giant esophageal hernias, such as abdominal pain
[8] [9], vomiting [10] [11], dysphagia [3], and
dyspnea [12]. In this case, the patient complained of dysphagia and
was found to have a giant hiatal hernia with pancreatic prolapse.
However, there are no reports of neoplastic lesions in the prolapsed
pancreas. In this case, the pancreas with a tumor requiring resection
had prolapsed into the posterior mediastinum due to a giant hiatal
hernia. We performed hiatal hernia surgery before pancreatic resection
to ensure that a safe pancreatic resection is conducted. Preceding
hiatal hernia repair allows pancreatic resection to be performed in the
normal anatomical position, thereby increasing safety of the procedure.
One study reported a case of pancreatitis and bile duct dilatation
secondary to a giant hiatal hernia of the pancreatic tail [13].
Therefore, pancreatic resection without esophageal hiatal hernia repair
in the present case may pose a risk of inflammation extending into the
mediastinum when complications, such as pancreatic fistula, develop.